Correlation between the skeletal muscle index and surgical outcomes of pancreaticoduodenectomy

Clinical impact of the prognostic nutritional index and skeletal muscle index for the incompletion of adjuvant chemotherapy for pancreatic cancer

BACKGROUND

Adjuvant chemotherapy is a standard therapeutic option for resected pancreatic cancer. However, the risk factors for incompletion of adjuvant chemotherapy remain unclear.

METHODS

We retrospectively reviewed the medical records of 72 patients who underwent radical pancreatectomy and received S-1 adjuvant chemotherapy for pancreatic cancer. The patients were assigned to two groups according to their completion or incompletion of adjuvant chemotherapy. We compared the perioperative skeletal muscle mass index (SMI) and nutritional status using prognostic nutritional index (PNI) between the two groups.

RESULTS

The completion and incompletion groups included 46 (64 %) and 26 (36 %) patients, respectively. Overall survival was shorter in the incompletion group than in the completion group (median survival time, 20.2 months vs. 42.0 months; log-rank, p = 0.018). Decreasing rate of PNI (12.7 % vs. 0.2 %, p = 0.010) and decreasing rate of SMI (26.9 % vs. 12.5 %, p = 0.001) were significantly larger in the incompletion group than in the completion group. Multivariate analysis showed that decreasing rate of PNI (p = 0.016), decreasing rate of SMI (p = 0.013), and old age (p = 0.049) were independent risk factors for incompletion of S-1 adjuvant chemotherapy. Regarding the time-series variations, PNI improved from 1 to 3 months after pancreatectomy in the completion group (p = 0.006). Furthermore, the decreasing slope of SMI was stronger in the incompletion group.

CONCLUSION

Postoperative decrease of PNI and SMI is associated with the incompletion of S-1 adjuvant chemotherapy.

High Prevalence of Sarcopenia in Patients with Newly Diagnosed Gastroenteropancreatic Neuroendocrine Tumours (GEP-NETs), but No Association with the Risk of Surgical Complications

Background: Sarcopenia is a muscle disease that occur across a lifetime. It is commonly described in the aging population but can occur earlier in life in patients with cancer. Previous studies demonstrated sarcopenia is highly prevalent in patients with gastroenteropancreatic neuroendocrine tumours (GEP-NETs). In solid organ cancers, such as colorectal or pancreatic cancer, the presence of sarcopenia is associated with surgical complications. It is unknown if sarcopenia in patients with GEP-NETs is a risk factor for surgical complications. Methods: A multicentre retrospective study was performed in patients with a recently diagnosed GEP-NET and surgery to the primary tumour. CT scans were analysed for body composition analyses to assess for the presence of sarcopenia. Data regarding surgical procedures and complications were collected. Any major surgical complication was considered as Clavien-Dindo score ≥ 3. Results: This study included 180 patients, with 83 being male (46%) with a median age of 62 years (IQR 54-69). Most patients (n = 138, 77%) had a small intestinal NET, while 36 patients (20%) had pancreatic NETs. Sarcopenia was present in 109 patients (61%). In 43 patients (24%), surgical complications were recorded, and 21 complications (49%) were considered as major. Any type of surgical complication was not statistically different between patients without sarcopenia (n = 17, 24%) and with sarcopenia (n = 26, 24%)-a p-value of 0.36. This was the same for major complications; between patients without sarcopenia (n = 5, 24%) and with sarcopenia (n = 16, 76%)-a p-value of 0.18. Conclusions: Sarcopenia is highly prevalent in patients with a recently diagnosed GEP-NET, but this is not associated with major surgical complications. Future studies should include pathophysiological mechanisms that could be used to identify the causes of sarcopenia, its effect on quality of life and other oncological outcomes.

The Association Between Preoperative Sarcopenia and Sarcopenic Obesity and the Occurrence of Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy for Periampullary Malignancies-A Literature Review

BACKGROUND

Sarcopenia and sarcopenic obesity, perceived as a reflection of cancer-induced cachexia, are often diagnosed in patients with periampullary malignancies. The pathophysiology of those conditions is multifactorial regarding the tumor microenvironment, immunological response, and the relationship to surrounding tissues.

METHODS

The PubMed and SCOPUS databases were systematically searched between November 2023 and December 2023. A total of 254 studies were primarily identified. Regarding the inclusion and exclusion criteria, 26 studies were finally included in the review.

RESULTS

Evaluated papers disclosed that sarcopenia was significantly associated with a higher incidence of postoperative complications, including pancreatic fistula (POPF) type B and C, with the odds ratio (OR) ranging from 2.65 (95%CI 1.43-4.93, p = 0.002) to 4.30 (95%CI 1.15-16.01, p < 0.03). Sarcopenic patients also suffered more often from delayed gastric emptying (DGE) with an OR of 6.04 (95%CI 1.13-32.32, p = 0.036). Infectious complications, postoperative hemorrhage, and intra-abdominal abscesses occurred more often in sarcopenic patients. Surgical complications were also noted more frequently when sarcopenic obesity was present. Preoperative nutritional prehabilitation seems to reduce the risk of postoperative complications. However, more prospective studies are needed.

CONCLUSIONS

Sarcopenia and sarcopenic obesity were associated with a higher incidence of multiple postoperative complications, including POPF (type B and C), DGE, hemorrhage, and infectious complications.

Association of preoperative CT-scan features and clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: a meta-analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk.

METHODS

Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139).

RESULTS

We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF.

CONCLUSION

Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.

Perioperative Rehabilitation in Collaboration with the Department of Occupational Medicine for Patients with Cholangiocarcinoma: A Case Report

INTRODUCTION

Although the number of cancer survivors has increased, the role of physical therapy in return to work (RTW) for employed patients with cancer remains unclear.

CASE PRESENTATION

The patient is a 50-year-old man diagnosed with cholangiocarcinoma who worked as a liquefied petroleum gas station filler. He started perioperative rehabilitation and underwent pancreaticoduodenectomy for cholangiocarcinoma. He developed a postoperative pancreatic fistula, which improved with conservative treatment over 40 days. Although he achieved independence regarding day-to-day activities, his physical condition and workability worsened, as his skeletal muscle index decreased from 8.7 to 7.7, 6-min walk distance from 518 to 460 m, and work ability index (WAI) from 37 to 20 points. His physical therapist was concerned about his RTW and recommended that he receive RTW support from the Department of Occupational Medicine (DOM). The DOM employed a team approach for the RTW strategy, and the primary physician, occupational physician, and company collaborated to support the patient. After the outpatient treatment protocol and RTW support plans were formulated, the patient was discharged. The physical therapist reported declining physical performance and WAI at the DOM's multidisciplinary conference. After consulting with multiple professionals, the team recommended work resumption in stages: part-time for three months and full-time for four months after surgery while undergoing oral adjuvant chemotherapy. The WAI improved to 35 points after RTW.

CONCLUSION

This case report suggests that physical therapists are vital in providing continuous patient support, from perioperative rehabilitation to DOM intervention, to build physical strength for return to work.

Prognostic impact of osteosarcopenia in patients undergoing pancreatic resection for pancreatic ductal adenocarcinoma

BACKGROUND

We investigated the prognostic impact of osteosarcopenia, defined as the combination of osteopenia and sarcopenia, in patients undergoing pancreatic resection for pancreatic ductal adenocarcinoma (PDAC).

METHODS

The relationship of osteosarcopenia with disease-free survival and overall survival was analyzed in 183 patients who underwent elective pancreatic resection for PDAC. Computed tomography was used to measure the pixel density in the midvertebral core of the 11th thoracic vertebra for evaluation of osteopenia and in the psoas muscle area of the 3rd lumbar vertebra for evaluation of sarcopenia. Osteosarcopenia was defined as the simultaneous presence of both osteopenia and sarcopenia. The study employed a retrospective design to examine the relationship between osteosarcopenia and survival outcomes.

RESULTS

Osteosarcopenia was identified in 61 (33%) patients. In the univariate analysis, disease-free survival was significantly worse in patients with male sex (p = 0.031), pathological stage ≥ III PDAC (p = 0.001), NLR, ≥ 2.71 (p = 0.041), sarcopenia (p = 0.027), osteopenia (p = 0.001), and osteosarcopenia (p < 0.001), and overall survival was significantly worse in patients with male sex (p = 0.001), pathological stage ≥ III PDAC (p = 0.001), distal pancreatectomy (p = 0.025), sarcopenia (p = 0.003), osteopenia (p < 0.001), and osteosarcopenia (p < 0.001). In the multivariate analysis, the independent predictors of disease-free survival were osteosarcopenia (p < 0.001) and pathological stage ≥ III PDAC (p = 0.002), and the independent predictors of overall survival were osteosarcopenia (p < 0.001), male sex (p = 0.006) and pathological stage ≥ III PDAC (p = 0.001).

CONCLUSION

Osteosarcopenia has an adverse prognostic impact on long-term outcomes in patients undergoing pancreatic resection for PDAC.

High hand grip strength is a significant risk factor and a useful predictor of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most critical complications of pancreaticoduodenectomy (PD). Studies on predictive factors for POPF that can be identified preoperatively are limited. Recent reports have highlighted the association between the preoperative nutritional status, including sarcopenia, and postoperative complications. We examined preoperative risk factors for POPF after PD, focusing on nutritional indicators.

METHODS

A total of 153 consecutive patients who underwent PD at our institution were enrolled in this study. Preoperative nutritional parameters, including hand grip strength (HGS) and skeletal muscle mass as components of sarcopenia, were incorporated into the analysis. POPFs were categorized according to the International Study Group of Pancreatic Fistula (ISGPF) definition as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C).

RESULTS

Thirty-seven of the 153 patients (24.1%) fulfilled the ISGPF definition of CR-POPF postoperatively. In the univariate analysis, the incidence of CR-POPF was associated with male sex, non-pancreatic tumor diseases, a high body mass index, a high HGS and a high skeletal muscle mass index. In the multivariate analysis, non-pancreatic tumor diseases and an HGS ≥23.0 kg were selected as independent risk factors for CR-POPF (P <0.05).

CONCLUSIONS

A high HGS, a screening tool for sarcopenia, was a risk factor for CR-POPF. It can accurately serve as a useful predictor of POPF risk in patients undergoing PD. These results highlight the potential of sarcopenia to reduce the incidence of POPF and highlight the need to clarify the mechanism of POPF occurrence.

Effect of sarcopenia on survival in patients after pancreatic surgery: a systematic review and meta-analysis

Background

Numerous studies have reported sarcopenia to be associated with unfavorable outcomes in patients who have undergone pancreatectomy. Therefore, in this meta-analysis, we examined the relationship between sarcopenia and survival after pancreatic surgery.

Methods

PubMed, Embase, and Cochrane Library were searched for studies that examined the association between sarcopenia and survival after pancreatic surgery from the inception of the database until June 1, 2023. Hazard ratio (HR) for overall survival (OS) and/or progression-free survival (PFS) of sarcopenia and pancreatic surgery were extracted from the selected studies and random or fixed-effect models were used to summarize the data according to the heterogeneity. Publication bias was assessed using Egger's linear regression test and a funnel plot.

Results

Sixteen studies met the inclusion criteria. For 13 aggregated univariate and 16 multivariate estimates, sarcopenia was associated with decreased OS (univariate analysis: HR 1.69, 95% CI 1.48-1.93; multivariate analysis: HR 1.69; 95% CI 1.39-2.05, I2 = 77.4%). Furthermore, sarcopenia was significantly associated with poor PFS of pancreatic resection (Change to univariate analysis: HR 1.74, 95% CI 1.47-2.05; multivariate analysis: HR 1.54; 95% CI 1.23-1.93, I2 = 63%).

Conclusion

Sarcopenia may be a significant prognostic factor for a shortened survival following pancreatectomy since it is linked to an elevated risk of mortality. Further studies are required to understand how sarcopenia affects long-term results after pancreatic resection.Systematic review registrationRegistration ID: CRD42023438208 https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Comparison of Muscle Mass Between Healthy Subjects and Patients With Malignant Tumors Undergoing Outpatient Treatment

Background In recent years, advances in the treatment of malignant tumors have improved life expectancy and diversified treatment options. However, maintaining high activities of daily living in patients is essential for appropriately treating the primary disease, and interventions for patients with impaired motor function will lead to improved quality of life. Here, we compared the muscle mass of malignant tumor patients who are visiting bone metastasis outpatient clinics with that of healthy subjects. Methods We compared the muscle mass of 61 malignant tumor patients with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 (mean 66.3 ± 12.0 years; 30 males and 31 females) attending our bone metastasis outpatient clinic since 2018 with that of 315 healthy subjects (mean 65.0 ± 17.7 years; 110 males and 205 females). Body mass index, skeletal muscle mass, and body fat percentage were assessed by bioimpedance analysis, and the skeletal muscle mass index (SMI) was calculated. Results To eliminate age bias in the malignant tumor patients and healthy subjects, 1:1 propensity score matching was performed separately for males and females. There was no significant difference in right upper limb, left upper limb, right lower limb, or left lower limb mass or SMI between the two groups, whereas trunk muscle mass and muscle mass were significantly higher in the healthy females compared with malignant tumor females. Conclusion There was no significant difference in the SMI measured by bioimpedance analysis between the two groups in either males or females, while muscle mass and trunk muscle mass were significantly lower in female malignant tumor patients than in healthy subjects. These results suggest that even malignant tumor patients whose performance status was maintained enough to allow outpatient visits still had impaired motor function.

Preoperative percent body fat in bioelectrical impedance analysis predicts pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

It is unclear which body composition affects postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy. In the present study, we evaluated the relationship between nutritional factors, body composition, and POPF.

METHODS

This was a prospective observational cohort study. Patients who underwent pancreaticoduodenectomy between March 2018 and July 2021 were included in this study. Preoperative body composition was measured using a bioelectrical impedance analyzer. In addition, the predictive factors for POPF were analyzed using logistic regression model.

RESULTS

The study included 143 patients. Among these patients, 31 had POPF (POPF group) and 112 did not (non-POPF group) after pancreaticoduodenectomy. For body composition, the percent body fat was significantly higher in the POPF group (26.90 vs 23.48, P = 0.022). Multivariate analysis revealed that alcohol consumption (odds ratio 2.95, P = 0.03), pancreatic duct < 3 mm (odds ratio 3.89, P < 0.01), and percent body fat (odds ratio 1.08, P = 0.01) were significantly independent predictive factors for POPF. When the patients were divided into three groups based on their percent body fat (< 25, 25-35, and ≥ 35), POPF occurred more frequently in the group with ≥ 35 percent body fat (47.1%) than in the < 25 group (15.5%) (P = 0.008).

CONCLUSION

Predictive factors for POPF related to nutritional status, such as percent body fat, should be considered before proceeding to pancreaticoduodenectomy (ClinicalTrials.gov trial registration no. NCT5257434).

Relationship between circulating tumour DNA and skeletal muscle stores at diagnosis of pancreatic ductal adenocarcinoma: a cross-sectional study

Low skeletal muscle index (SMI) and low skeletal muscle radiodensity (SMD) are associated with reduced survival time in pancreatic ductal adenocarcinoma (PDAC). The negative prognostic impact of low SMI and low SMD is often reported as independent of cancer stage when using traditional clinical staging tools. Therefore, this study sought to explore the relationship between a novel marker of tumour burden (circulating tumour DNA) and skeletal muscle abnormalities at diagnosis of PDAC. A retrospective cross-sectional study was conducted in patients who had plasma and tumour tissue samples stored in the Victorian Pancreatic Cancer Biobank (VPCB) at diagnosis of PDAC, between 2015 and 2020. Circulating tumour DNA (ctDNA) of patients with G12 and G13 KRAS mutations was detected and quantified. Pre-treatment SMI and SMD derived from analysis of diagnostic computed tomography imaging was tested for its association to presence and concentration of ctDNA, as well as conventional staging, and demographic variables. The study included 66 patients at PDAC diagnosis; 53% female, mean age 68.7 years (SD ± 10.9). Low SMI and low SMD were present in 69.7% and 62.1% of patients, respectively. Female gender was an independent risk factor for low SMI (OR 4.38, 95% CI 1.23-15.55, p = 0.022), and older age an independent risk factor for low SMD (OR 1.066, 95% CI 1.002-1.135, p = 0.044). No association between skeletal muscle stores and concentration of ctDNA (SMI r = - 0.163, p = 0.192; SMD r = 0.097, p = 0.438) or stage of disease according to conventional clinical staging [SMI F(3, 62) = 0.886, p = 0.453; SMD F(3, 62) = 0.717, p = 0.545] was observed. These results demonstrate that low SMI and low SMD are highly prevalent at diagnosis of PDAC, and suggest they are comorbidities of cancer rather than related to the clinical stage of disease. Future studies are needed to identify the mechanisms and risk factors for low SMI and low SMD at diagnosis of PDAC to aid screening and intervention development.

Pre-Therapeutic Sarcopenia among Cancer Patients: An Up-to-Date Meta-Analysis of Prevalence and Predictive Value during Cancer Treatment

This study will address the prevalence of pre-therapeutic sarcopenia (PS) and its clinical impact during cancer treatment among adult cancer patients ≥ 18 years of age. A meta-analysis (MA) with random-effect models was performed via a MEDLINE systematic review, according to the PRISMA statement, focusing on articles published before February 2022 that reported observational studies and clinical trials on the prevalence of PS and the following outcomes: overall survival (OS), progression-free survival (PFS), post-operative complications (POC), toxicities (TOX), and nosocomial infections (NI). A total of 65,936 patients (mean age: 45.7-85 y) with various cancer sites and extensions and various treatment modes were included. Mainly defined by CT scan-based loss of muscle mass only, the pooled prevalence of PS was 38.0%. The pooled relative risks were 1.97, 1.76, 2.70, 1.47, and 1.76 for OS, PFS, POC, TOX, and NI, respectively (moderate-to-high heterogeneity, I²: 58-85%). Consensus-based algorithm definitions of sarcopenia, integrating low muscle mass and low levels of muscular strength and/or physical performance, lowered the prevalence (22%) and heterogeneity (I² < 50%). They also increased the predictive values with RRs ranging from 2.31 (OS) to 3.52 (POC). PS among cancer patients is prevalent and strongly associated with poor outcomes during cancer treatment, especially when considering a consensus-based algorithm approach.

Prevalence of Sarcopenia and Impact on Survival in Patients with Metastatic Gastroenteropancreatic Neuroendocrine Tumours

Sarcopenia in patients with cancer is associated with adverse outcomes such as shorter survival. However, there exists little evidence regarding the prevalence of sarcopenia in patients with metastatic gastroenteropancreatic neuroendocrine tumours (GEP-NETs). Patients with a histologically confirmed newly diagnosed metastatic GEP-NET between 2006 and 2018, CT scan, and anthropometric data at diagnosis were included in this study. CT scans were analysed for the presence of sarcopenia and correlated with overall survival (OS). In total, 183 patients, 87 male (48%), with a median age of 62 years (IQR 52-68 years), were included. In 44 patients (24%), there was a pancreas NET, and in 136 patients, there was a small bowel NET (74%). Sarcopenia was present in 128 patients (69%) and unrelated to BMI (median 25.1). There were significant survival differences between patients with pancreatic and small bowel NETs at 86 vs. 141 months, respectively (p = 0.04). For patients with pancreatic NETs, the presence of sarcopenia was independently associated with shorter OS (HR 3.79 95% CI 1.1-13.03, p-value 0.035). A high prevalence of sarcopenia at the time of diagnosis of a metastatic GEP-NET was seen and associated with worse OS in patients with pancreatic NETs. Further research should focus on how to reverse sarcopenia and its impact on OS and/or quality of life.

Impact of Preoperative Muscle Mass Maintenance and Perioperative Muscle Mass Loss Prevention After Pancreatectomy: Association Between Perioperative Muscle Mass and Postoperative Nutritional Status

OBJECTIVES

We investigated how preoperative sarcopenia and perioperative muscle mass changes affect postoperative nutritional parameters in patients undergoing pancreatectomy.

METHODS

This study included 164 patients undergoing pancreatectomy between January 2011 and October 2018. Skeletal muscle area was measured by computed tomography before and 6 months after surgery. Sarcopenia was defined as the lowest sex-specific quartile, and patients with muscle mass ratios less than -10% were classified into the high-reduction group. We examined the relationship between perioperative muscle mass and postoperative nutritional parameters 6 months after pancreatectomy.

RESULTS

There were no significant differences in nutritional parameters between the sarcopenia and nonsarcopenia groups at 6 months after surgery. In contrast, albumin (P < 0.001), cholinesterase (P < 0.001), and prognostic nutritional index (P < 0.001) were lower in the high-reduction group. According to each surgical procedure, albumin (P < 0.001), cholinesterase (P = 0.007), and prognostic nutritional index (P < 0.001) were lower in the high-reduction group of pancreaticoduodenectomy. In distal pancreatectomy cases, only cholinesterase (P = 0.005) was lower.

CONCLUSIONS

Postoperative nutritional parameters were correlated with muscle mass ratios but not with preoperative sarcopenia in patients undergoing pancreatectomy. Improvement and maintenance of perioperative muscle mass are important to maintain good nutritional parameters.

Sarcopenia and Risk of Pancreatic Fistula after Pancreatic Surgery: A Systematic Review

Postoperative pancreatic fistula (POPF) is one of the most critical complications after pancreatic surgery. The relationship between sarcopenia and outcomes following this type of surgery is debated. The aim of this review was to assess the impact of sarcopenia on the risk of POPF. A literature search was performed using the PubMed database and the reference lists of relevant articles to identify papers about the impact of sarcopenia on POPF in pancreatic surgery. Twenty-one studies published between 2016 and 2021 with a total of 4068 patients were included. Some studies observed a significant difference in the incidence of POPF between the sarcopenic and non-sarcopenic patients undergoing pancreatoduodenectomy. Interestingly, there was a trend of a lower POPF rate in sarcopenic patients than in non-sarcopenic patients. Only one study included patients undergoing distal pancreatectomy specifically. The role of sarcopenia in surgical outcomes is still unclear. A combination of objective CT measurements could be used to predict POPF. It could be assessed by routine preoperative staging CT and could improve preoperative risk stratification in patients undergoing pancreatic surgery.

Prognostic Value of Pretreatment Skeletal Muscle Mass Index in Esophageal Cancer Patients: A Meta-Analysis

The prognostic role of pretreatment skeletal muscle mass index (SMI) has been verified in several types of cancers. However, it remains unclear whether pretreatment SMI is a valuable prognostic indicator in esophageal cancer. The aim of the present study was to identify the prognostic value of pretreatment SMI in esophageal cancer. PubMed, EMBASE and Web of Science databases were searched for relevant studies up to November 10, 2021. The hazard ratios (HRs) with 95% confidence intervals (CIs) were combined to assess the association of pretreatment SMI with the overall survival (OS) and disease-free survival (DFS) of esophageal cancer patients. In total, 17 studies involving 2441 patients were included in this meta-analysis. The pooled results demonstrated that a lower SMI was significantly associated with poorer OS (HR = 1.18, 95% CI: 1.09-1.27, P < 0.001) and DFS (HR = 1.78, 95% CI: 1.10-2.88, P = 0.019). In addition, subgroup analysis based on treatment (surgery vs. nonsurgery), tumor type (squamous cell carcinoma vs. adenocarcinoma) and cutoff value of SMI showed similar results. The present findings demonstrated that pretreatment SMI is an independent prognostic indicator for esophageal cancer patients, and patients with a lower pretreatment SMI are more likely to have a worse prognosis. However, additional prospective high-quality studies are needed to verify the above findings.

The Relationship between Phase Angle, Nutrition Status, and Complications in Patients with Pancreatic Head Cancer

Phase angle (PhA), a bioimpedance parameter, is used to assess the nutrition status and body composition of patients. Patients with pancreatic head cancer often present with body composition changes that relate to adverse outcomes. PhA may be useful to evaluate prognosis in these patients, but data are deficient. We aim to explore the effects of PhA on nutrition evaluation and short-term outcome prediction in these patients. This prospective study included 49 participants with pancreatic head cancer who underwent pancreaticoduodenectomy (PD). All participants’ nutritional status and postoperative complications were assessed using nutrition assessment tools and the Clavien−Dindo classification method, respectively. Spearman correlation analyses were used to evaluate the association between PhA, nutrition status, and postoperative complications. ROC curves were generated to evaluate the ability of PhA to predict malnutrition and complications and to determine the cutoff value. The PhA values of the nutritional risk group and the malnourished group were significantly lower than those of the well-nourished group (p < 0.05). PhA positively correlated with patients’ nutrition status. Nineteen patients had postoperative complications, and the PhA value of the complication group was significantly lower than that of the non-complication group (4.94 vs. 5.47, p = 0.013). ROC curves showed that the cutoff point of PhA to predict malnutrition was 5.45 (AUC: 0.744), and the cutoff point of PhA to predict postoperative complications was 5.35 (AUC: 0.717). Our study indicates that PhA was associated with nutrition status and could be considered a nutrition assessment tool for pancreatic head cancer patients and predict the postoperative complications of these patients who have undergone PD.

Deep Learning-Based Abdominal Muscle Segmentation on CT Images of Surgical Patient Populations

Computed tomography (CT) is commonly used for the characterization and tracking of abdominal muscle mass in surgical patients for both pre-surgical outcome predictions and post-surgical monitoring of response to therapy. In order to accurately track changes of abdominal muscle mass, radiologists must manually segment CT slices of patients, a time-consuming task with potential for variability. In this work, we combined a fully convolutional neural network (CNN) with high levels of preprocessing to improve segmentation quality. We utilized a CNN based approach to remove patients' arms and fat from each slice and then applied a series of registrations with a diverse set of abdominal muscle segmentations to identify a best fit mask. Using this best fit mask, we were able to remove many parts of the abdominal cavity, such as the liver, kidneys, and intestines. This preprocessing was able to achieve a mean Dice similarity coefficient (DSC) of 0.53 on our validation set and 0.50 on our test set by only using traditional computer vision techniques and no artificial intelligence. The preprocessed images were then fed into a similar CNN previously presented in a hybrid computer vision-artificial intelligence approach and was able to achieve a mean DSC of 0.94 on testing data. The preprocessing and deep learning-based method is able to accurately segment and quantify abdominal muscle mass on CT images.

Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy

BACKGROUND

Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF.

METHODS

A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included.

RESULTS

Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI95% ) 23-30) and 19% (CI95% 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF.

CONCLUSION

In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.

The prognostic impact of skeletal muscle status and bone mineral density for resected distal cholangiocarcinoma

BACKGROUND & AIMS

The preoperative body composition and bone mineral density (BMD) have been reported as prognostic factors for several cancers. However, the prognostic impact of the preoperative body composition and BMD for resected distal cholangiocarcinoma (DCC) remains unclear.

METHODS

A total of 111 patients who underwent pancreatoduodenectomy for DCC between 2002 and 2017 were analyzed. The skeletal muscle index (SMI) and BMD were measured by preoperative computed tomography. The optimal cut-off value of the body composition and BMD were selected based on the minimum P-value obtained by the log-rank test. The prognostic significance of the preoperative body composition and BMD was investigated using multivariate analysis.

RESULTS

The median values of the SMI (45.7 vs. 36.7 cm²/m², P < 0.001) and BMD (128.5 vs. 101.0 Hounsfield units [HU], P = 0.005) in male and female were significantly different. The optimal cut-off values for the SMI were 55 cm²/m² in male and 36 cm²/m² in female, and those for the BMD were 75 HU in male and 74 HU in female. A multivariate analysis identified low SMI (hazard ratio [HR], 4.340; P = 0.044), low BMD (HR, 5.333; P < 0.001) and microscopic venous invasion (HR, 2.019; P = 0.026) as independent prognostic factors for the survival.

CONCLUSIONS

A preoperative low SMI and low BMD were independent prognostic factors for resected DCC.

Prediction of clinically relevant pancreatic fistula after pancreatic surgery using preoperative CT scan: A systematic review and meta-analysis

BACKGROUND

Body composition analysis has emerged as a practical tool for predicting outcomes following pancreatic surgery. However, the impact of body composition disorders on clinically relevant postoperative pancreatic fistula (CR-POPF) remains inconclusive. The aim of this study was to review and analyse whether radiographically assessed body composition is predictive of CR-POPF.

METHODS

PubMed, MEDLINE, Web of Science, and the Cochrane Library databases were searched up to January 2020 to identify relevant studies. CR-POPF was defined according to the definition and grading system proposed by the International Study Group on Pancreatic Surgery (ISGPS). Pooled odds ratios (OR) for CR-POPF were calculated to evaluate the predictive values of radiographically assessed body composition.

RESULTS

Fifteen studies published between 2008 and 2019 with a total of 3136 patients were included. There was a significant increase in the incidence of CR-POPF in patients with visceral obesity (OR 2.97, 95% CI 2.05-4.29, P < 0.00001) and sarcopenic obesity (OR 2.88, 95% CI 1.31-6.34, P = 0.009). Conversely, the impact of sarcopenia (OR 0.91, 95% CI 0.65-1.28, P = 0.59) and low muscle attenuation (MA) on CR-POPF did not reach statistical significance.

CONCLUSION

Preoperative visceral obesity and sarcopenic obesity are more effective at predicting CR-POPF than decreased muscle quantity and quality. This finding may lead to appropriate management and early intervention of patients at risk of CR-POPF.

Cancer cachexia and treatment toxicity

PURPOSE OF REVIEW

Cancer cachexia is a metabolic disturbance resulting in a loss of skeletal muscle mass that is generally not reversed through traditional nutritional interventions. We review on both the impact of nutritional status on cancer treatment side effects, as well as cancer- specific outcomes.

RECENT FINDINGS

Cancer-specific cachexia and sarcopenia are associated with increased treatment-associated toxicity, and overall worse cancer-specific outcomes across all cancer types in surgical, chemotherapeutic, and radiotherapeutic populations. Despite the fact that cancer cachexia is generally thought to be irreversible, there is some evidence that nutritional intervention can be helpful.

SUMMARY

Nutritional status is an important factor to consider in determining cancer therapy. Patients with poor nutritional status should be identified prior to the initiation of therapy and be monitored judiciously.

Preoperative anthropomorphic and nutritious status and fistula risk score for predicting clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a life-threatening postoperative complication. The aim of this study was to evaluate the efficacy of the fistula risk score (FRS) and preoperative body composition factors for predicting the occurrence of clinically relevant POPF (CR-POPF) after pancreaticoduodenectomy (PD).

Methods

In this study, 136 consecutive patients who underwent PD between 2006 and 2018 were enrolled. The risk factors of CR-POPF (grades B and C) were analyzed. Preoperative visceral adipose tissue area (VATA), skeletal mass index (SMI), and subcutaneous adipose tissue area (SATA) were calculated from computed tomography data.

Results

The overall 30-day mortality and morbidity rates were 0.7 and 38%, respectively. The incidence rates of grade B and C CR-POPF were 27 and 4%, respectively. A univariate analysis revealed that male sex, habitual smoking, prognostic nutritional index (PNI) < 45, VATA ≥90, VATA/SATA ≥0.9, VATA/SMI ≥ 1.4, and FRS > 4 were significantly associated with the incidence of CR-POPF. A multivariate analysis revealed that PNI < 45, VATA/SMI ≥ 1.4 and FRS > 4 were the independent risk factors of CR-POPF.

Conclusions

Preoperative anthropomorphic imbalance, PNI, and FRS were independent risk factors for CR-POPF. Patients with high-risk factors should be closely monitored during the postoperative period.

The 2019 ESPEN Arvid Wretlind lecture perioperative nutritional and metabolic care: Patient-tailored or organ-specific approach?

BACKGROUND & AIM

The perioperative severe changes in the nutritional and metabolic homeostasis are, by some means, proportional to the extent of tissue injury and magnitude of operative trauma. An adequate qualitative and quantitative replacement of nutritional substrates are of utmost importance to facilitate proper tissue healing and recovery and maintenance of organ function after surgery.

METHODS

The present manuscript has been planned to put the most recent research of the Milano-Bicocca University surgical working group in the context of a more personalized nutritional therapy and metabolic care for surgical patients. Particular prominence has been given to major pancreatic resections because these surgeries are among the most complex and challenging operations for the degree of parenchyma resection and tissue dissection, the consequent overall injury, and the fairly high rate of major complications resulting in a catabolic response.

RESULTS

Anthropometric parameters and particularly sarcopenia, visceral obesity - and their relative proportion -, are strongly associated with poor outcome after pancreatic surgery. Adequate perioperative nutritional therapy is of utmost importance in affecting morbidity. Long-term nutritional and metabolic sequelae, caused by exocrine pancreatic insufficiency, need to be promptly recognized and treated with an adequate enzyme supplementation.

CONCLUSIONS

There is strong evidence sustaining the necessity of proper perioperative metabolic and nutritional care into the management of patients undergoing major pancreatic surgery.

Low skeletal muscle mass and postoperative morbidity in surgical oncology: a systematic review and meta-analysis

BACKGROUND

Sarcopenia might function as an indicator for frailty, and as such as a risk factor for the development of postoperative complications. The aim of this study was to meta-analyse the relation between preoperative sarcopenia and the development of severe postoperative complications in patients undergoing oncological surgery.

METHODS

PubMed and Embase databases were systematically searched from inception until May 2018. Included were studies reporting on the incidence of severe postoperative complications and radiologically determined preoperative sarcopenia. Studies reporting the skeletal muscle as a continuous variable only were excluded. Data were extracted independently by two reviewers. Random effect meta-analyses were applied to estimate the pooled odds ratio (OR) with 95% confidence intervals (95% CI) for severe postoperative complications, defined as Clavien-Dindo grade ≥3, including 30-day mortality. Heterogeneity was evaluated with I2 testing. Analyses were performed overall and stratified by measurement method, tumour location and publication date.

RESULTS

A total of 1924 citations were identified, and 53 studies (14 295 patients) were included in the meta-analysis. When measuring the total skeletal muscle area, 43% of the patients were sarcopenic, versus 33% when measuring the psoas area. Severe postoperative complications were present in 20%, and 30-day mortality was 3%. Preoperative sarcopenia was associated with an increased risk of severe postoperative complications (ORpooled : 1.44, 95% CI: 1.24-16.8, P<0.001, I2 =55%) and 30-day mortality (ORpooled : 2.15, 95% CI: 1.46-3.17, P<0.001, I2 =14%). A low psoas mass was a stronger predictor for severe postoperative complications compared with a low total skeletal muscle mass (ORpooled : 2.06, 95% CI: 1.37-3.09, ORpooled : 1.32, 95% CI: 1.14-1.53, respectively) and 30-day mortality [ORpooled : 6.17 (95% CI: 2.71-14.08, ORpooled : 1.80 (95% CI: 1.24-2.62), respectively]. The effect was independent of tumour location and publication date.

CONCLUSIONS

The presence of low psoas mass prior to surgery, as an indicator for sarcopenia, is a common phenomenon and is a strong predictor for the development of postoperative complications. The presence of low total skeletal muscle mass, which is even more frequent, is a less informative predictor for postoperative complications and 30-day mortality. The low heterogeneity indicates that the finding is consistent over studies. Nevertheless, the value of sarcopenia relative to other assessments such as frailty screening is not clear. Research is needed in order to determine the place of sarcopenia in future preoperative risk stratification.

Pancreatic Fat and Body Composition Measurements by Computed Tomography are Associated with Pancreatic Fistula After Pancreatectomy

OBJECTIVES

Postoperative pancreatic fistula (POPF) is the most threatening complication after pancreatectomy. This study aimed to directly assess pancreatic fatty infiltration with preoperative computed tomography (CT) imaging and to investigate whether a preoperative analysis of patient variables, including CT characteristics and clinical factors, can predict POPF.

METHODS

We enrolled 150 consecutive patients who underwent curative pancreatectomy. Radiographic factors, including pancreatic fat volume, were measured using preoperative CT imaging and the predictive factors were explored using univariate and multivariate analyses.

RESULTS

POPF developed in 30 patients (20.0%). The ratio of pancreatic fat (RPF) ≥ 4.83% was associated with a risk of POPF, high body mass index (BMI), and obese body habitus. Patients with POPF were significantly more likely to have high BMI (≥ 25 kg/m²), obese body habitus, and an RPF ≥ 4.83% than patients without POPF. In the multivariate analysis, visceral fat area/skeletal muscle index (VFA/SMI) ≥ 1.94 (odds ratio [OR] 4.28, 95% confidence interval [CI] 1.43-12.9, p = 0.0095) was the sole independent predictive factor for POPF. For patients with a soft pancreas, VFA/SMI ≥ 1.94 (OR 5.67, 95% CI 2.05-15.7, p = 0.0008) was again the sole independent predictive factor for POPF.

CONCLUSION

Preoperative CT images can examine pancreatic fatty infiltration, and patients who had POPF were significantly associated with a high RPF. Among several parameters, VFA/SMI was the only independent predictive factor for clinically relevant POPF. Preoperative evaluation of these body composition variables and the pancreatic configuration could be useful for predicting POPF.

The psoas muscle index as a predictor of mortality and morbidity of geriatric trauma patients: experience of a major trauma center in Kobe

PURPOSE

An association between the prognoses of trauma and sarcopenia has not been well documented. The purpose of this study was to compare the outcomes of elderly Japanese trauma patients with sarcopenia and those without sarcopenia.

METHODS

The medical records of patients aged ≧ 65 years old and Injury Severity Scores above 15 treated for trauma between 2010 and 2017 were reviewed, retrospectively. We measured the psoas muscle index (PMI), defined as the psoas muscle area at the third lumbar vertebra level divided by the body surface area. Patients of each gender with a PMI less than the lower interquartile range were included in the sarcopenia group. A questionnaire was mailed to the patients or their families to collect data on 1-year mortality and activities of daily living.

RESULTS

There were 405 patients included in this study: 304 in the non-sarcopenia group (Group NS) and 101 in the sarcopenia group (Group S). Mortality was significantly higher in Group S than in Group NS (NS; 7.9% vs. S; 15.8%, OR, 2.20; 95% CI, 1.12-4.32; p = 0.027). Only 175 of the questionnaires were completed and the responses did not reveal any significant differences between the groups.

CONCLUSIONS

Sarcopenia as defined by the PMI may be used as an indicator for mortality risk for geriatric trauma patients.

Influence of sarcopenia in major pancreatic surgery. A systematic review of the literature

Post-operative morbidity of pancreatectomies occurs in up to 40-50% of patients, even in modern series. There is a need to find a simple scale in order to identify patients with increased risk of developing major post-operative complications after pancreatic resections. Many studies have been published on sarcopenia and surgical outcomes. Aspects of sarcopenia are presented, along with a systematic review using PRISMA guidelines, in order to search for articles about sarcopenia and pancreatic surgery. The impact of sarcopenia on morbidity and mortality in pancreatic resections is still unclear. The studies presented have been carried out over long periods of time, and many of them compare patients with different diseases. There are also different definitions of sarcopenia, and this can influence the results, as some of the reviewed articles have already shown. It is necessary to unify criteria, both in the definition and in the cut-off values. Prospective studies and consensus on sarcopenia diagnosis should be achieved.

Combined test of third lumbar skeletal muscle index and prognostic nutrition index improve prognosis prediction power in resected colorectal cancer liver metastasis

Background: In this paper, we aim to explore clinical value of skeletal muscle index (SMI) and prognostic nutrition index (PNI) on resected colorectal cancer liver metastasis (CRLM).

Results: Among the 539 patients, 355 were males. Baseline lower SMI was associated with smaller BMI, smaller PNI, smaller pre-albumin and longer hospitalization days (P<0.05). Patients with lower SMI and PNI had significantly shorter duration of PFS and OS (P<0.05). SMI can reflect the postoperative treatment response. Postoperative 6-month’s and 12-month’s SMI and PNI can indicate overall prognosis. When combined SMI and PNI, prognostic AUC of ROC curves improved significantly.

Conclusion: Combined monitor of SMI and PNI can improve the power at predicting prognosis. Postoperative 6-month’s record of SMI and PNI was more accurate and predictive for CRLM prognosis.

Method: A total of 539 resected CRLM patients between January 2013 to December 2016 with complete clinical data were included. Computed tomography image was collected from each patient. Receiver-operating characteristic (ROC) curves were constructed; area under curves (AUC) were also determined. All clinical variables were analyzed in proper way.

Power of computed-tomography-defined sarcopenia for prediction of morbidity after pancreaticoduodenectomy

BACKGROUND

The goal of our study was to evaluate the current approach in prediction of postoperative major complications after pancreaticoduodenectomy (PD), especially symptomatic pancreatic fistula (POPF), using parameters derived from computed tomography (CT).

METHODS

Patients after PD were prospectively collected in a database of the local department of surgery and all patients with CT scans available were assessed in this study. CT parameters were measured at the level of the intervertebral disc L3/L4 and consisted of the areas of the visceral adipose tissue (AVAT), the diameters of the pancreatic parenchyma (DPP) and the pancreatic duct (DPD), the areas of ventral abdominal wall muscle (AMVEN), psoas muscle (AMPSO), paraspinal muscle (AMSPI), total muscle (AMTOT), as well as the mean muscle attenuation (MA) and skeletal muscle index (SMI). Mann-Whitney-U Test for two independent samples and binary logistic regression were used for statistical analysis.

RESULTS

One hundred thirty-nine patients (55 females, 84 males) were included. DPD was 2.9 mm (Range 0.7-10.7) on median and more narrow in patients with complications equal to or greater stadium IIIb (p < 0.04) and severe POPF (p < 0.01). DPP median value was 17 (6.9-37.9) mm and there was no significant difference regarding major complications or POPF. AVAT showed a median value of 127.5 (14.5-473.0) cm2 and was significantly larger in patients with POPF (p < 0.01), but not in cases of major complications (p < 0.06). AMPSO, AMSPI, AMVEN and AMTOT showed no significant differences between major complications and POPF. MA was both lower in groups with major complications (p < 0.01) and POPF (p < 0.01). SMI failed to differentiate between patients with or without major complications or POPF.

CONCLUSION

Besides the known factors visceral obesity and narrowness of the pancreatic duct, the mean muscle attenuation can easily be examined on routine preoperative CT scans and seems to be promising parameter to predict postoperative complications and POPF.

Malnutrition, frailty, and sarcopenia in pancreatic cancer patients: assessments and interventions for the pancreatic surgeon

The objective of this article is to review the available literature examining the impact of malnutrition, frailty, and sarcopenia on surgical morbidity among pancreatic cancer patients. We examine definitions used to diagnose and quantify these conditions and review the differences between them with regards to preoperative assessment and postoperative outcomes. The most relevant scoring systems are summarized. Lastly, we summarize current knowledge regarding effectiveness of specific interventions aimed at malnutrition, frailty, and sarcopenia for patients undergoing pancreatic cancer surgery.

Impact of preoperative sarcopenia on postoperative outcomes following pancreatic resection: A systematic review and meta-analysis

BACKGROUND

Morphometric analysis of sarcopenia has garnered interest due to its putative role in predicting outcomes following surgery for a variety of pathologies, including resection for pancreatic disease. However, there are no standard recommendations on whether sarcopenia is a clinically relevant predictor of outcomes in this setting. The aim of this study was to review the prognostic impact of preoperatively diagnosed sarcopenia on postoperative outcomes following pancreatic resection.

METHODS

A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases until May 2018.

RESULTS

Thirteen studies, including 3608 patients, were included. There was a significant increase in the mean duration of post-operative hospital stay (mean difference of 0.73 days, CI: 0.06-1.40, P = 0.033), there was no difference in the postoperative outcomes, including: clinically relevant postoperative pancreatic fistula, delayed gastric emptying, post-operative bile leak, surgical site infection, significant morbidity and overall morbidity.

CONCLUSION

Preoperative sarcopenia is associated with prolonged hospital stay after pancreatic surgery. However, sarcopenia does not appear to be a significant negative predictive factor in postoperative morbidity although study heterogeneity and risk of bias limit the strength of these conclusions.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

BACKGROUND

The optimal nutritional therapy in the field of pancreatic surgery is still debated.

METHODS

An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group.

RESULTS

The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement.

CONCLUSION

The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.